Wednesday, January 5, 2011

Dog eat dog vs. the "Nanny" State

David Leonhardt has a good article in the NYT on the history of opposition to government health care plans. He talks in length about how vehement opposition rooted in claims of liberty and freedom have been endemic to progressive causes throughout the country's history. His take on the battle lines of this conflict seem a bit too simplistic:

The opposition stems from the tension between two competing traditions in the American economy. One is the laissez-faire tradition that celebrates individuality and risk-taking. The other is the progressive tradition that says people have a right to a minimum standard of living — time off from work, education and the like.

This seems to cast the progressive tradition as only calling for social safety nets, almost vulgar Marxist in nature. That notion that the free enterprise system only provides people's wants, but not their needs, thus progressives are the fighters for life's necessities. Though, this is a proper characterization of many of progressives' goals, i.e. health care for all, affordable housing, public transportation etc, this seems to not really answer Leonhardt's characterization of the laissez-faire tradition in relation to its view of the individual. You can support individual opportunity, yet still believe that health care for all allows the best opportunity for people to achieve that.

I think a better characterization of the conflict would be something I've seen repeated by Paul Starr over and over again in his seminal history of American medicine. His view of the conflict first appears in his discussion in the medical professions fight over licensing schemes. On one side, were the medical doctors that were following the experimental tradition of medicine. These doctors mirror modern doctors. They liked to focus on experimentation, and repetition of results that were effective. Furthermore, they put their utmost confidence in science's ability to come to grips with tackling emerging and existing disease. On the other side, were herbalist, spiritual healers, and generic quacks, who preached simple, sweeping cures for diseases, think cure-all elixirs here. They expounded on the notion that empiricist doctors were elitists trying to keep the common man from curing themselves. In the fight over licensing, their two viewpoints were put into direct contrast. The experimental, modern-method doctors argued that individuals did not have the information to assess the effectiveness of the medical practitioners they were visiting. In modern lingo, there was an information asymmetry that medical licensing was meant to solve. Consumers could just not ever really understand who was better, so licensing was there to provide an easy heuristic for individuals to determine which doctors were effective. On the other side, the quacks supported the notion that the individual had the right to choose, and if a doctor was bad then people would just not choose them, thus driving them out of business.

This seems to be the place where Leonhardt misses the fundamental difference in progressive and laissez faire traditions, how it grapples with the individual swimming through a sea of information. Laissez faire proponents believe in freedom to choose, while progressives, to borrow Louis' coinage, believe in the tyranny of choice, a la more choice does not make better decisions. Though, the health care bill attempted to solve many of the basic needs issues that Leonhardt discusses, with its requirements for basic benefits offered, no denial of pre-existing conditions and other aspects of the legislation, it also attempted to resolve some of these informational deficits. It's funding for increased comparative effectiveness research, the IPAB board in Medicare, as well as, the tax on cadillac plans, were all attempts to allow the consumer the best choices possible by informing, and in some cases, limiting them to the most effective treatment and insurance options. Overall a great article, though, well worth a read.